Ppo annual-report-2012-13

N PRISONS AND PROBATION O
DSMAN OMBUDSMAN PRISON
PROBATION OMBUDSMAN PRIS
EPORT ANNUAL REPORT ANNU
2012 – 2013

Prisons and Probation Ombudsman

Annual Report
2012–2013

Presented to Parliament
by the Lord Chancellor and Secretary of State for Justice
by Command of Her Majesty
September 2013
Cm 8702

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Annual Report 2012–2013

Contents
CHALLENGING TIMES 6
THE YEAR IN FIGURES 12
INVESTIGATING FATAL INCIDENTS 16
Learning lessons about fatal incidents

17

Individual investigations

18

Reception health screening

18

Checking prisoners at unlock

20

Emergency response

21

Diabetes care

22

Food refusal

24

Enhanced case reviews

25

Personality disorders

26

Emerging themes from homicide investigations

27

Family liaison

29

INVESTIGATING COMPLAINTS 32
Learning lessons about complaints

33

Individual complaints

34

Serious complaints

35

Links with the outside world

39

Property 40
Adjudications 41
Religious issues

43

Categorisation 43
Early release

44

Women and young offenders

44

Immigration detention

46

Probation 47
APPENDICES 48
Statistical tables 49
Financial data 59
Stakeholder feedback 60
Learning lessons publications 2012–13 62
Performance against business plan 63
Prisons and Probation Ombudsman Terms of Reference 70
Staff list 76

3

PRISONS AND PROBATION OMBUDSMAN FOR ENGLAND AND WALES

4


Vision
To be a leading, independent investigatory body, a model to others,
that makes a significant contribution to safer, fairer custody and
offender supervision.

Values
• We are independent, impartial, fair and honest in all our dealings,
internally and externally.
• We take pride in delivering both quality and value for money.
• We have respect for, listen to and respond to each other, the users of our
service and wider stakeholders.
• We celebrate diversity, both internally and externally, so that everyone can
give their best.
• We approach our work with determination, dedication and integrity.
• We are committed to improvement through learning lessons internally and
influencing how lessons are learned externally.

5


CHALLENGING TIMES


With the services I investigate under pressure,
it is unsurprising that demand for my office’s
services remains high. In some ways, the
cases reaching my desk are an indication
of the strains in the system – and, I would
argue, evidence of the need for a robustly
independent mechanism to offer redress
to those in custody or on probation with
legitimate complaints, as well as the need
to ensure impartial analysis of how to avoid
future fatal incidents in custody.

The past year has been a challenging
one for all those involved with custody
or probation. The prison population has
stabilised but remains proportionately
higher than anywhere else in Western
Europe and it is also rapidly ageing. As
resources have shrunk, so have regimes
and staffing levels. Meanwhile, Ministers
are understandably concerned that
more needs to be done to rehabilitate
prisoners and reduce future crime. They
have put in place an extensive programme
to ‘transform rehabilitation’, with
rationalisation of the prison estate, more
competitive tendering and various reforms
to ensure offenders are ‘properly punished
and incentivised to turn away from crime’.

These strains are perhaps also reflected in the
increasing proportion of complaints where we
found fault in the services under investigation.
Last year there was a substantial rise in the
proportion of complaints upheld (from 23% to
31%) and in the number of recommendations
for improvement. I have sought to ensure that
there is absolute clarity about the remedial
action required, so recommendations are
now more prescriptive, time-bounded and
outcome focused. This adds to expectations
on prison, probation and immigration services,
so it is commendable that they continue to
accept almost all our recommendations, put in
place improvement plans and – usually – learn
appropriate lessons.
Of course, I recognise that there can be a cost
to implementing recommendations, but not
always: an apology is free. Moreover, it can
be even more costly not to learn lessons (and
some important joint work is underway with
the National Audit Office to explore this point).

These are indeed challenging times.

“ In such a challenging context, it is pleasing to
look back on my first full year in post and see
some significant improvements in my office’s
performance.”
7


In such a challenging context, it is pleasing to
look back on my first full year in post and see
some significant improvements in my office’s
performance. Despite the inevitable need for
year on year savings1 and some intractable
recruitment difficulties, there has been
progress on many of the key commitments
I made on appointment, notably: better
timeliness in the production of fatal incident
reports, improved and more proportionate
complaint handling and development of a
substantial learning lessons agenda, as well
as putting in place some necessary internal
reforms.

Quicker and better information to
bereaved families and coroners
Loss of a loved one in the closed and hidden
world of custody is perhaps harder to
bear than in any other circumstance. Little
information is readily available and confidence
in the adequacy and accuracy of that
information can be limited. A major role of
my office is to shine a light into this secretive,
hidden world and provide an impartial
explanation of what actually happened in a
fatal incident, so that lessons can be identified
and preventable deaths avoided in future.
Unfortunately, my office has had a poor
recent record in producing timely investigation
reports into deaths in custody. This has added
to families’ distress and contributed to the
excessively slow coronial system. In 2010–11,
only 16% of draft fatal incident reports met
our time targets. This figure rose slightly in
2011–12 to 21%. But in the past year, given a
clear strategic focus on timeliness and sheer
hard work by my staff, the figure jumped to
55%. This is an important move in the right
direction.

1

8

The Prisons and Probation Ombudsman’s budget
will fall 14% between 2010–11 and 2014-15.

This progress was aided by close working with
Primary Care Trusts to improve and expedite
the reviews of clinical care required in all our
fatal incident investigations. While most clinical
reviews still miss our targets, their overall
timeliness and quality have improved. We
have now put in place arrangements with NHS
England to build on this progress.

“ A major role of my
office is to shine a
light into this secretive,
hidden world and
provide an impartial
explanation of what
actually happened in a
fatal incident, so that
lessons can be identified
and preventable deaths
avoided in future.”
So a start has been made but, with shrinking
resources, we have also had to be more
proportionate. This has meant targeting efforts
on fatal incident investigations where there
may be most to learn – such as last year’s
three tragic child deaths – while introducing
a more standardised approach where a
death from natural causes was reasonably
foreseeable. However, every death in custody
must be independently investigated2 and
lessons can be learned even where death
is entirely predictable. It is depressing, for
example, how frequently I have had to criticise
the inappropriate use of restraints on elderly,
infirm and dying detainees.
2

Article 2 of the Human Rights Act


“ Ultimately, however, my fatal incident
investigations are of limited merit if they do not
help bereaved families come to terms with their
loss. It is therefore gratifying to have improved
our levels of positive feedback in recent surveys
of families.”
Ultimately, however, my fatal incident
investigations are of limited merit if they do
not help bereaved families come to terms with
their loss. It is therefore gratifying to have
improved our levels of positive feedback in
recent surveys of families.3

Improving our handling of
complaints
There has been no let up in demand for my
office’s other main activity: the independent
investigation of complaints. The overall
number of complaints increased by 2% last
year and, after a concerted communication
campaign, the proportion of eligible
complaints increased from 51% to 59%. This
is important as it is frustrating to complain to
my office only to be told that the complaint
is ineligible because, for example, the
internal complaint mechanism of the prison,
immigration removal centre or probation trust
concerned has not been exhausted.
However, increasing eligibility also increases
demand. Once again, proportionality is key.
Scarce resources must be targeted on the most
serious cases, such as allegations of assault,
bullying and racism. These can be complex
investigations in which we have to interview
the complainant, other detainees and staff.
We need to get these cases right as detainee
safety, as well as staff careers, may be at
Prisons and Probation Ombudsman Bereaved
Family Survey 2011–13

3

stake. It is a key part of my office’s function to
ensure that independent investigation helps
to eradicate abuse in custody4 and later in this
report there are some troubling examples of
poor staff behaviour where, after thorough
and robust investigation, we have had to
recommend disciplinary action.
But if resources are targeted at serious cases,
less remain for other complaints. While small
issues can mean a lot to detainees with very
little, not all eligible cases merit investigation
and one size of investigation does not fit
all. Accordingly, we have had to decline to
investigate complaints where no worthwhile
outcome is likely and to withdraw cases
which are no longer relevant. We have also
introduced an unreasonable complainant
policy to ensure offensive or threatening
behaviour to my staff is not tolerated and
scarce resources are not inappropriately
consumed by prolific complainants.
None of this, however, should suggest a
stepping back from insistence on improvement
in custody or probation trusts where this
is necessary. Such rigour and robustness is
clearly evidenced by the increased proportion
of complaints upheld and the greater number
of recommendations to right wrongs or make
improvements – but this is now being done in
a more targeted and proportionate way.
Nor are the challenges likely to reduce.
Article 3 of the Human Rights Act

4

9


“ It is a key part of my office’s function to
ensure that independent investigation helps to
eradicate abuse in custody.”
Changes in other parts of the criminal justice
system may impact on my office. For example,
there have been cases where the new,
streamlined Prison Service internal complaints
system appears to be leading to us receiving
poorly investigated complaints – and we will
have no hesitation in sending such cases back
to be dealt with properly. I am also carefully
monitoring the uncertain implications of the
prospective changes to legal aid for prisoners.
There is a long way to go. While our
assessment of the eligibility of complaints has
quickened, the timeliness of investigations
has slipped. While more complaints are being
upheld, perceptions of my office amongst
complainants are too closely tied to whether
they succeed. More needs to be done to
convince them that, even if their complaint has
not been upheld, they have had a fair hearing.
In a pressurised context, we may even get
some cases wrong and where this happens we
must apologise, learn lessons and improve.
My office must do more for less but in doing
so my staff and I will always be guided by an
unwavering commitment to supporting fairer
custody and offender supervision.

“ There is a long
way to go.”

Learning lessons
A key part of the new vision for my office
is to identify and disseminate lessons from
investigations. Our primary job is to investigate
individual cases, but if we are to contribute
more generally to improving safety and fairness,
we must encourage services to learn the lessons
that can avoid the next complaint and help avoid
the next preventable death. To this end, the
past year has seen the creation of a significant
agenda of learning lessons materials.5
The first of this year’s two thematic studies
(which look at large samples of investigations)
explored the many complaints we receive
about the prison disciplinary system. In
around a fifth (21%) of cases, we found the
adjudication unsafe and called for it to be
quashed. This reflects poor practice. Many
cases should have been resolved by the Prison
Service without coming to my office at all and
there is a general learning point about the need
for better adjudication training for prison staff.
The second thematic study looked at
investigations into end of life care for the
growing numbers of mainly elderly prisoners
known to have a terminal illness, whose final
days are spent in custody. The study suggested
prisons are making some headway in adjusting
to the growing challenge of providing decent
care for the terminally ill, but care remains
variable and occasionally unacceptable. While
learning for improvement is identified, a
question must remain as to whether prison
can ever be the best place for those reaching
the last days and hours of their life.
See appendices for a full list of publications
2012–13.

5

10


A new series of learning lessons bulletins now
offer expeditious, topical guides based on
small numbers of cases. The first two bulletins
focused on probation issues. One identified
the need for probation trusts to manage their
internal complaint process better, including
avoiding ‘buck passing’ between prisons and
probation. The other looked, for the first time,
at deaths in probation approved premises,
and identified the need for better awareness
of methadone and mixed drug toxicity
and improved management of prescribed
medication.

“ A key part of the
new vision for my
office is to identify and
disseminate lessons
from investigations.”
A subsequent bulletin focused on learning
from the tragic sequence of self-inflicted
child deaths in custody in 2011–12. Three
deaths occurred within a few months and,
to varying degrees, each investigation found
that more needed to be done to ensure an
appropriately holistic, child-centred approach
to managing the risks presented by the most
vulnerable children in custody. This included
the ability of authorities to allocate to settings
equipped to keep children safe – something
with which busy young offender institutions
with essentially adult-orientated processes
can struggle. The bulletin was provided
to Ministers to inform their review of the
juvenile secure estate. I am also pleased that
the National Offender Management Service
(NOMS) and the Youth Justice Board have set
up a working group to review suicide and selfharm prevention arrangements for juveniles in
light of our findings.

Further bulletins have looked at the growing
number of complaints about religious issues
and another at sexual abuse in prison. A
further bulletin flagged up the failure of too
many prisons to ensure an appropriate balance
between security and humanity in the use
of physical restraints on elderly, infirm and
dying detainees. Finally, a bulletin explored
links between suicide and Incentives and
Earned Privileges (IEP) levels, finding that fatal
incidents disproportionately occurred among
prisoners on the basic level of privileges and
emphasising the need for prisons to balance
the management of challenging behaviour and
vulnerabilities. This bulletin was also sent to
Ministers to help inform their review of the IEP
scheme.
So, the year has seen a much greater emphasis
on learning lessons. The task now is to ensure
services act on our findings. My staff will
continue to refine these publications to ensure
they can really contribute to improvement.

Enhancing independence
I concluded the introduction to last year’s
annual report by regretting that, despite
various attempts over the years, my office
had still not been put on a statutory footing.
This damages my actual and perceived
independence. While I am pleased that
Ministers have repeated their commitment
to this change, no legislative opportunity has
yet been found. I will continue to press for
my independence to be reinforced. It would
buttress the commitment of my office to
contribute robustly and impartially to safer and
fairer custody and probation supervision – a
commitment that is reflected throughout this
annual report.

Nigel Newcomen
11


THE YEAR IN FIGURES


Fatal incidents
•

We were notified of 201 deaths in
2012–13 (9 of which were not investigated
as they were outside our remit) and we
started 192 investigations, 37 (16%) fewer
than last year.

•

We were notified of 2 murders, compared
to 1 last year.

Timeliness improved dramatically, with
60% of natural cause reports and 47%
of self-inflicted reports issued on time,
compared to only 22% and 19% last year.

•

The average time taken to produce a
natural cause draft report was 28 weeks,
6 weeks shorter than last year. The average
time for self-inflicted cases was 40 weeks,
three weeks shorter than last year.

•

Completed investigations included some
very high profile and complex ones,
including the first 3 self-inflicted child
deaths in nearly five years.

•

Our annual stakeholder survey indicated
some improved satisfaction with
timeliness. Bereaved families also rated
their experience more highly, with 85%
stating it was ‘above average’ compared
to 77% in 2009.

There were 118 deaths from natural causes
and 55 which were apparently selfinflicted.

•

•

•

•

9 cases were classified as ‘other nonnatural’ and a further 8 await classification
(last year there were six such cases, all
of which were subsequently classified
as either natural causes or other nonnatural).
Output increased significantly, with 247
draft reports and 242 final reports issued
in 2012–13, compared to 212 and 196
last year.

Fatal incident investigations
160
140

Natural causes

120

Self-inflicted

100

Other non-natural

80

Homicide

60

Awaiting
classification

40
20
0
2004–05 2005–06 2006–07 2007–08

2008–09 2009–10

2010–11

2012–12

2012–13

13

WALES

Complaints
•

5,374 complaints were received this year,
80 more than last year. Of these 4,894
(91%) were about the Prison Service, 369
(7%) were about the Probation Service
and 111 (2%) were about immigration
detention.

•

Greater proportionality was introduced,
with more cases (376) not investigated
because there was no substantial issue or
worthwhile outcome. A further 303 cases
were withdrawn, for example because the
complainant had been released.

•

The eligibility rate for complaints rose to
59% this year from 51% in 2011–12.

•

•

Overall, 2,815 investigations were started,
a 6% increase on last year.

•

Although more investigations were
started, 298 (13%) fewer were completed
compared to last year. A total of 2,062
investigations were completed: 1,986
about prisons, 38 about immigration
removal centres and 38 about probation,
reflecting (as in previous years) the lower
eligibility of probation cases.

Timeliness of assessments improved
significantly this year, with 64%
completed within the 10-working day
target compared to 40% last year. On
average assessments took 11 working
days to complete, an improvement from
15 days in 2011–12.

•

Timeliness of investigations fell this year
(with 33% completed within 12 weeks,
compared to 53% last year) and on
average, investigations increased from 14
weeks in 2011–12 to 19 weeks this year.

Complaints completed
500

2011–12

2012–13

450
400
350
300
250
200
150
100
50

14

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0


•

Overall, 31% of cases were upheld, a
marked increase on last year when 23%
were upheld. Over half of property cases
investigated were upheld, compared to
42% last year. Adjudications saw the
biggest increase in uphold rate, rising from
17% to 38% this year.

•

Of the 4,894 prison cases received, 1,164
(24%) were from high security prisons.
The uphold rate (26%) for completed
cases was lower than the 33% average for
other prisons.

•

Complaints covered a wide range of
subjects, with property being the largest
single category, making up 18% of all
complaints and 24% of immigration
detention complaints.

•

Like last year, 39 people (less than 3%
of the total number who complained)
each made more than seven complaints
accepted for investigation in the year.
These accounted for 523 cases, 19% of
the PPO’s caseload.

•

In our annual stakeholder survey, 63%
of respondents felt investigations were
completed in a reasonable time (or better).
Data from the new complainant survey
suggest satisfaction levels vary sharply
depending on whether the complaint was
upheld or not.

15


INVESTIGATING
FATAL INCIDENTS


Learning lessons about fatal
incidents
As part of our continued commitment to
ensuring that investigations contribute to
wider learning, we produced a thematic
review and five Learning Lessons bulletins on
fatal incidents this year drawing out common
themes from across investigations.6
Perhaps the most poignant of these was the
bulletin reviewing the apparently self-inflicted
deaths of three children in custody, the first
such deaths in nearly five years. The bulletin
was produced much earlier than would have
been the case in the past to ensure that any
lessons could be drawn to the attention of
the authorities and quickly learned, with
the earnest hope that such tragedies can be
averted in future.
A number of learning points emerged about
the need to improve the safeguarding of
vulnerable children in custody. Some have
been identified in the past, including poor
sharing of information within and between
agencies and the need to manage bullying
better. Others proved particularly topical, for
example the need to ensure an appropriate
custodial location for the most vulnerable
children, an issue that was fed into the
Government’s review of the juvenile secure
estate. The bulletin also found the need for
more child-centred processes to manage
effectively the risk of suicide and self-harm
among children. It is positive that the National
Offender Management Service (NOMS) and
the Youth Justice Board have established a
working group to address this issue.
With an increasingly ageing prison population,
and a number of younger prisoners with
serious health conditions, caring for those
coming to the end of their life is a growing
responsibility for the Prison Service. We
therefore published a thematic review of the
6

See appendices for the full list of publications.

“ A number of learning
points emerged about
the need to improve
the safeguarding of
vulnerable children in
custody.”
end of life care for 214 prisoners who died of
terminal illness between 2007 and 2012. While
end of life care was found to have improved in
recent years, weaknesses remained. Thus, our
clinicians assessed the medical care received
by most prisoners as equivalent to that they
might have expected in the community, but
provision was still patchy. Learning points
included the need for: comprehensive palliative
care planning, greater involvement of families,
earlier application for release on temporary
licence or compassionate grounds, and more
appropriate use of restraints.

“ Unfortunately, the
inappropriate use of
restraints on seriously
ill and dying prisoners
is an issue that has
arisen in too many
investigations this year.”
Unfortunately, the inappropriate use of
restraints on seriously ill and dying prisoners
is an issue that has arisen in too many
investigations this year. It was, therefore,
the subject of a dedicated learning lessons
17

WALES

bulletin, which stressed the need to balance
security with humanity when assessing the
use of restraints on very ill, often low risk and
frail prisoners. This is an issue that needs to
be addressed, whether by better guidance,
improved training or simply the application of
humane common sense.

Individual investigations
The overall number of deaths in custody
notified to this office last year fell 16% from
the record number in 2011–12. As previously,
around two-thirds of these deaths were
from natural causes and around a third were
apparently self-inflicted. There were slightly
fewer ‘other non-natural’ cases (usually drug
related) and an increase in the small but
troubling number of homicides.
At a time of diminishing resources, it is
particularly pleasing to note that there was a
dramatic improvement in the timeliness of our
investigations and in production of reports.
This is important as it assists in the learning of
urgent lessons, avoids contributing to delays in
the inquest system and, above all, provides a
better service to bereaved families.

“ As previously,
around two-thirds of
these deaths were
from natural causes
and around a third
were apparently selfinflicted.”

18

Our fatal incident investigations reflect a
broad range of issues which are explored
in the following pages. Some are familiar
themes, including the need to improve health
screening, safety checks and emergency
responses. Other issues reflect the range of
challenges facing the services we investigate,
including the difficulties in managing the
personality disordered, those who refuse
food and the growing numbers of diabetes
sufferers, as well as some emerging themes
from a number of complex investigations into
homicides.

Reception health screening
Prison Service Instruction (PSI) 74/2011 sets out
clearly the expectations for the reception of
prisoners, as well as first night and induction
into custody. It also covers the expectations in
relation to reception health screening.
All newly arrived prisoners should be assessed
by a qualified member of the healthcare
team or a competent healthcare assistant to
determine whether they have any short- or
long-term physical or mental health needs,
including disability, drugs or alcohol issues and
whether there are any immediate needs. Any
health records transferred with the prisoner
must be examined as part of the assessment.
Follow-up action should be taken, including
ensuring that anyone who needs to know
about the individual’s on-going healthcare
requirements is informed, appropriate referrals
are made (such as to the substance misuse
team or GP) and the assessment and any
action taken is recorded in the healthcare
record.
Healthcare staff carrying out reception
health screening should be ACCT trained
(assessment, care in custody and teamwork)
and if a prisoner is identified as being at risk of
suicide or self-harm an ACCT must be opened
or an existing ACCT followed up.


We continue to investigate deaths where
reception health screening has been poor.
In many cases, previous records are not
examined, either because they have not arrived
with the prisoner or are simply not taken into
account. SystmOne (the computerised prison
healthcare record) should have overcome this,
but too often little or no consideration is given
to the historical record, the summary page has
not been completed, or health concerns have
not been flagged. Community health records
are often not requested, so a full picture of a
prisoner’s clinical history is not available. There
is too much reliance on information from the
prisoner, rather than information contained
in previous records of any conditions and
treatment.

“ We continue to
investigate deaths
where reception health
screening has been
poor.”

We have also seen some disturbing cases,
where there has been a failure to follow up
significant findings in the reception screening,
putting the prisoner at risk of serious
complications.
Ms A arrived in prison directly from
court. She did not speak English,
but was clearly distressed. The nurse
carrying out the reception health
screen used a telephone interpretation
service and completed and recorded
a thorough reception health screen.
Ms A’s blood pressure was recorded as
dangerously high. However, the nurse
did not call a GP and did not make
any arrangements for any further
monitoring of Ms A. Apart from
recording the blood pressure reading,
the nurse did not flag up the issue for
follow-up or evaluation.
The following day, Ms A was seen
by the GP as part of the routine
assessment. He did not read Ms A’s
medical record and did not use a
telephone interpretation service to
assist with his consultation. As a result,
he did not notice the high blood
pressure reading, and concluded that
Ms A was fit and well. Three days
later, Ms A was rushed to hospital and
found to have malignant hypertension
resulting in aortic dissection. This means
she had severely high blood pressure
leading to irreversible damage to her
heart, where blood is forced between
layers of the aorta forcing the layers
apart. The condition was inoperable
and Ms A died four days later. The
clinical reviewer concluded that, had Ms
A been taken to hospital immediately
her high blood pressure was noted,
there might have been a better
outcome.
19

WALES

“ In at least 10 of our
investigations in the
last year we found
that officers failed to
get a response from
a prisoner when they
unlocked their cell.”

We made recommendations about the use of
tools to identify and quickly address indicators
of serious concerns about blood pressure at a
health screen and to flag these up for other
clinicians in the prisoner’s medical record.
We also recommended that healthcare
professionals use a telephone translation
service when assessing prisoners who do not
speak and understand English well.

Checking prisoners at unlock
Prison Service guidance requires that officers
check the wellbeing of prisoners when they
unlock their cells. Nevertheless, in at least 10
of our investigations in the last year we found
that officers failed to get a response from a
prisoner when they unlocked their cell, usually
in the morning. In some cases, the prisoner
was dead when the cell was unlocked, but the
officer made no check and failed to notice.
In others, the prisoner was seriously unwell,
but again the failure to elicit any response
from the prisoner at unlock meant this went
unnoticed and led to delays in the prisoner
receiving treatment.
Mr B was found dead in his cell by
another prisoner who was concerned
that he had not seen him that morning.
The prisoner then raised the alarm. The
officer who had unlocked Mr B’s cell
could not recall if he had even seen
him when he unlocked the cell. Had
staff carried out their duties properly,
the prisoner who found him would
not have been put in this distressing
situation.
In many of our investigations, officers told
us that there was no requirement to get a
response from a prisoner when unlocking
their cell. However, officers are trained to get
a positive response from a prisoner when
they unlock a cell. The purpose of this check
is to confirm that the prisoner has not escaped,
and is not ill or dead. In each of the cases we
investigated where this did not happen, we
recommended that Governors ensure that
officers understood their duty to check prisoners’
wellbeing when they unlock their cells.

20


Emergency response
Life-threatening medical emergencies can
occur in prisons whether as a consequence
of natural causes, self-harm or other reasons.
However, an emergency in a custodial setting
presents particular challenges. Speed of
response is always critical to the chances
of survival but this can be hampered by
prison security, such as arrangements for
entering a cell at night, calling an ambulance
or unlocking several wing gates to reach a
prisoner.
During the period covered by this report, we
made a total of 143 recommendations about
emergency response (six related to deaths
in immigration removal centres). Many of
these repeated concerns that were identified
in our 2012 thematic study, Deaths from
circulatory diseases. These included recurring
recommendations for quicker identification of
symptoms and the nature of the emergency,
better delivery of emergency first aid and
automatic summoning of an ambulance in lifethreatening emergencies.
Mr C told his cellmate that he had
severe pains in his chest, at around
9.45pm, but did not think he needed
the intervention of staff. Forty-five
minutes later, his cellmate summoned
staff as he was concerned Mr C might
be in a coma. The officer who attended
instructed Mr C’s cellmate to try to
rouse him by shaking him and dripping
water on his face. The officer believed
Mr C was breathing as he saw his torso
moving in and out. As there was no
response to the attempts at stimulation,
he called the senior officer in charge of
the prison that night.

The senior officer and three officers
went to the cell but two of the officers
refused to enter as there was a strong
smell. The senior officer said he felt a
pulse as well as signs of breathing and
assumed Mr C had had an epileptic fit.
He decided to let him ‘sleep it off’. He
cancelled the request for emergency
assistance that had been made a few
minutes earlier and asked an officer
to keep an eye on him. About once an
hour throughout the night, the officer
checked Mr C, by looking through the
observation hatch of the cell with his
torch. He noticed that he remained
lying in the same position all night.
At around 6.20am the following
morning, Mr C’s cellmate found him
unresponsive, cold and stiff. He had
been dead for some hours.

“ When seeking help
for an unconscious
person, every second
counts and we are
concerned that we
have investigated
many cases where
prison staff have been
reluctant to open
and enter a cell in an
emergency.”
21

WALES

The post-mortem report stated that, if Mr C
had been taken to hospital immediately after
his collapse, ‘his prognosis would have been
markedly improved’ and there was ‘…no
fundamental reason why he would not have
survived had he been taken to hospital’. We
concluded that the staff involved had failed in
their duty of care to Mr C.
When seeking help for an unconscious person,
every second counts and we are concerned that
we have investigated many cases where prison
staff have been reluctant to open and enter a
cell in an emergency. Even a few minutes delay
can compromise the chances of survival.
A fellow prisoner found Mr D collapsed
in his cell ‘making gurgling noises and
waving his arms about’. He sought
help from staff and two officers went
to Mr D’s cell. It was early evening and
there were no healthcare staff on duty.
The officers could not find a pulse and
noticed Mr D was not breathing. Both
officers concluded that he had died
and neither considered attempting
resuscitation. One of them called the
senior officer in charge of the prison,
who radioed all staff that there was an
emergency where a prisoner was not
breathing and asked the control room
to call an ambulance. Another senior
officer joined him at the cell. Neither
examined Mr D, but both accepted the
officers’ view that he had died without
any further enquiry.

“ As with the general
population, there is an
increasing number of
people with diabetes in
prison.”
22

The senior officer in charge did not
specifically request staff trained in
cardiopulmonary resuscitation (CPR)
to attend. He did not look for the list
of such staff, find out if one of the
prisoners had such training or get a
defibrillator from the wing office.
Neither did the senior officers remain
at the cell to coordinate the emergency
response. A paramedic arrived at Mr D’s
cell and, after attaching a defibrillator,
concluded that too much time had
elapsed without intervention for CPR
to stand any chance of success. He
therefore confirmed that Mr D had died.

Diabetes care
Diabetes is a chronic condition that affects
the body’s ability to process sugar or glucose
which can have serious health consequences.
Left untreated, diabetes can lead to heart
disease, stroke, nerve damage and blindness.
However, if managed effectively, people with
diabetes can reduce the risk of complications
and reduce the day-to-day symptoms.
As with the general population, there is an
increasing number of people with diabetes
in prison, possibly reflecting the rise in the
number of older prisoners. We have been
concerned to have seen a number of cases
where the management of diabetes has been
poor, in terms of medication management,
day-to-day monitoring of blood glucose
levels and the long-term management of the
disease. In particular, in the cases we have
investigated, few prisoners had received the
important HbA1c test (an average plasma
glucose test carried out once every three to six
months) as part of their diabetic care. When
investigating deaths in custody, we look to see
that the healthcare provided is equivalent to
what might be expected in the community. In
respect of diabetes care, too often we have
found this has not been the case.


The National Institute of Clinical Excellence
(NICE) publishes guidelines for the care and
management of diabetes and we consider
this to be a cornerstone of good practice for
prisons and other places of detention.
Mr E was 38 years old when he died.
The post-mortem report showed he
died of diabetic ketoacidosis (usually
caused by a lack of insulin where the
body switches to burning fatty acids
and produces ketones, which are
harmful) secondary to an infection
caused by norovirus. Mr E was a type 1
insulin-dependent diabetic.
When Mr E first arrived at the prison his
blood glucose levels were not checked.
Two months later an HbA1c test showed
a higher than desirable blood glucose
level. Mr E was also found to have
raised albumin/creatinine levels (which
could indicate kidney damage). Both
of these results could have indicated
that Mr E was at risk of complications
from his diabetes, yet there was no
diabetic follow-up. Mr E developed
diarrhoea and vomiting during an
outbreak of norovirus at the prison.
The prison concentrated on managing
the containment of the outbreak rather
than ensuring the needs of individual
prisoners were met.
Mr E’s diabetes was not appropriately assessed
during this time and his deteriorating condition
was not noticed. He had various symptoms
that indicated raised ketones, including
vomiting, abdominal pain and mental
confusion. We considered that healthcare
staff should have been particularly alert to
the possible affects of the virus on a diabetic
patient and the risk of raised ketones and
subsequently ketoacidosis.

We made a number of recommendations
about the management of diabetic prisoners, the
use of NICE guidelines and the management of
prisoners with existing health conditions during
an outbreak of a communicable disease.
Mr F died unexpectedly and a postmortem showed heart disease caused
by diabetes. He was diagnosed with
type 2 diabetes in January 2012, but it
is likely that he had been diabetic for
some time. Mr F had been in prison
since 2010 and had spent time in three
different prisons in the 12 months
before his death. There was no urine
dip-testing as part of routine health
screens at any of the prisons.
In November 2011, Mr F complained of
deteriorating eyesight and was referred
to an optician, who found changes in
Mr F’s retina consistent with diabetes.
Blood tests were not taken until the
end of December, the results of which
showed raised blood glucose. Type 2
diabetes was diagnosed in January.
Once diagnosed, the care planning and
monitoring of Mr F’s diabetes was poor
across the three prisons he spent time
in. He did not have an HbA1c test and
there was no on-going care plan. We
could find no evidence that Mr F was
initially referred to a diabetic clinic,
however this did happen in his final
prison.
We found that Mr F’s diabetes was poorly
controlled. We were critical that there
was no urine dip-testing as part of routine
health screens at any of the prisons, which
would have indicated Mr F’s diabetes much
earlier and allowed treatment to begin. Left
untreated, high blood glucose levels can
cause hardening of the arteries and raise the
risk of heart disease. Doctors made changes
to his medication, but his on-going diabetic
23

WALES

care was not equivalent to the care he might
have expected in the community. We made a
recommendation about appropriate screening
for diabetes and the need for diabetic
prisoners to be managed in line with NICE
guidelines.

Food refusal
In England and Wales, deaths of prisoners
who make a conscious decision to stop eating
are fortunately rare. In the first five years that
the Ombudsman’s office was responsible for
investigating deaths in custody, we reported
on only one death directly attributed to food
refusal. More recently, we have investigated
two such deaths. Cases where prisoners refuse
to eat are challenging and distressing for
those involved in caring for them. Staff have
to ensure that the individual understands the
seriousness of refusing food and later refusing
life-supporting treatment, but the starting
assumption must always be that the prisoner
has the capacity to make such a decision. In
the cases we investigated, we were satisfied
that appropriate efforts had been made to
establish that the prisoner did not lack this
capacity.
When considering the earlier death, we
noted the ‘professionalism and sensitivity
demonstrated by staff and management’ at
the prison. Nevertheless, we recommended
that NOMS and the Department of Health
should prepare a briefing about care for a
prisoner who is determined to die through
food refusal. The Department of Health
published guidelines for managing such cases
from a healthcare perspective, in January
2010.7

7

24

Department of Health (2010) Guidelines for the
clinical management of people refusing food in
immigration removal centres and prisons.

Mr G began refusing food shortly after
moving prisons. The prison immediately
opened an ACCT form, setting out the
support and monitoring that could
be provided for him. He was assessed
daily and staff frequently attempted
to persuade him to reconsider his
decision. Despite their best efforts,
Mr G continued to fast and drew up
an advance directive with his solicitor,
refusing further medical treatment. All
staff and carers who had contact with
Mr G were made aware of the terms of
the directive and what it allowed them
to do for him.
Mr G’s condition gradually worsened,
and he was admitted to hospital where
he reaffirmed to hospital staff that he
did not want to be resuscitated. Two
days after he was admitted, some four
months after he first refused food, Mr
G died in his sleep.
No recommendations were made as a result
of this investigation as we found that Mr G
had been cared for both professionally and
compassionately. However, we endorsed a
recommendation from the clinical reviewer
that more prison staff should be trained to
provide end of life care.


Mr H returned to prison from a secure
mental health hospital. He told staff
when he arrived that he had been
refusing food for two months, after he
had learned that he would be returned
to prison.
Mr H also inflicted wounds on his arms,
which he refused to let staff treat. Staff
made several attempts to encourage
him to eat and accept treatment, but he
continued to refuse and was assessed
as having capacity to do so. He was
eventually taken to hospital after his
physical health deteriorated and died of
abscesses, which were probably a result
of the lack of treatment for his wounds.
In this case, we again thought that staff at
the prison had given Mr H appropriate care
and advice about managing his decision to
refuse food while he was in prison. However,
we made two recommendations about care
arrangements for prisoners with mental
health issues when they return from secure
psychiatric hospitals and about wound
management.

Enhanced case reviews
Under Prison Service procedures to manage
prisoners regarded as at risk of suicide and
self-harm, prisons have the discretion to
manage the most severely disruptive, volatile
and difficult to manage prisoners under an
enhanced case review process. In some cases
it is mandatory. Enhanced case reviews are
designed to allow staff to respond more
effectively to prisoner’s individual needs and
provide a flexible but consistent approach
to changing the prisoner’s behaviour and
managing their risk. We do not see much
evidence of enhanced case reviews being used
and in five of our investigations into selfinflicted deaths reported on in the last year we

found that enhanced case reviews might have
improved the outcome. All of the prisoners
involved were 21 or under.

“ We do not see much
evidence of enhanced
case reviews being
used and in five of
our investigations into
self-inflicted deaths
reported on in the last
year we found that
enhanced case reviews
might have improved
the outcome.”
Mr I, who was 21, struggled to cope
with the restrictions of prison life
and a clear trigger to his volatile and
impulsive behaviour was being unable
to speak to his girlfriend or family. He
frequently threatened serious selfharm. He was sometimes threatening
and abusive towards staff and was
often accused of misusing his cell bell.
The responsibility for dealing with Mr
I’s challenging behaviour fell largely
on wing officers and there was no
formal strategy setting out how Mr I’s
behaviour should best be managed.
There was little evidence of a robust
and consistent approach being taken or
of more than sporadic attempts being
made to encourage Mr I to reflect on
or address his behaviour. His conduct
deteriorated.
25

WALES

Membership of an enhanced case review
should include ‘more specialists and a higher
level of operational management’ than a
typical suicide and self-harm case review. The
guidance suggests that a representative of the
mental health team, the residential manager,
the personal officer, a psychologist, a
member of the chaplaincy team, the offender
supervisor and any other specialists working
with the prisoner should be invited, as well
as the prisoner. With such diverse and senior
representation, the review should be able to
establish a full picture of the individual’s needs
and tailor the support measures accordingly.
For a significant proportion of Ms J’s
time in custody she was subject to
suicide prevention monitoring, because
she self-harmed by cutting and tied
several ligatures around her neck.
At the same time, she was described
as disruptive, and was managed on
the basic regime. Ms J’s self-harm
was managed using standard suicide
prevention procedures. Behaviour
that was classified as ‘disruptive’
was managed separately under the
behaviour management scheme and,
in reaction to her more aggressive
behaviour, she was given periods of
cellular confinement as a punishment
for disciplinary offences, despite her
identified risk of self-harm.
The risks of self-harm and disruptive behaviour
were managed separately in both of these
cases. There was no holistic consideration
at a multi-disciplinary forum of the range
of behaviour and what it might mean. It is
easy to label prisoners as disruptive, but once
given this label it can be very difficult to
remove. Often it is the behaviour itself that
then becomes the focus of staff’s attention.
The possible root causes of a prisoner’s
behaviour are often overlooked. Enhanced
26

case reviews should be used more frequently
to manage prisoners whose needs cannot be
easily categorised according to existing prison
procedures, particularly for young people and
young adults under 21.

Personality disorders
Many prisoners suffer from mental health
problems. Not all of these are mental illnesses
which are superimposed on a person’s
usual personality and may be treatable
with interventions such as medication or
counselling. Personality disorders, on the
other hand, result in extreme behaviour that
tends to last throughout the person’s life.
They are difficult to treat and treatment often
includes helping the person to manage their
disorder rather than attempting to ‘cure’ it.
The following examples demonstrate the
difficulties prison staff face in managing
prisoners with challenging behaviour, and
also the need to ensure that mental health
problems are not ignored because there is no
easily diagnosed and treatable illness. However
the manifestation of mental health problems
is defined, these are still people exhibiting real
symptoms of distress and there is a need to
ensure appropriate care.
Ms K often failed to collect food and
medication, suffered from incontinence,
and did not dispose of the pads she was
given to help her. She also had mobility
issues, although some members of staff
thought that she sometimes displayed
better mobility than she told them. Ms
K’s physical health was poor and led to
her death but she had mental health
and behavioural issues which were
not addressed and resulted in some of
her basic care needs not being given
appropriate priority.


In Ms K’s case, healthcare staff were unable
to find a medical reason for the incontinence
and advised prison staff to use the discipline
system to try and change her behaviour. In the
meantime, her health began to deteriorate.
While our clinical reviewer did not think the
care provided to her contributed to her death,
he noted that a caring approach to her basic
nursing and social care needs was lacking.
Although it was clear that she was difficult to
manage because of her behavioural problems,
more should have been done to examine
possible underlying health, mental health
or behavioural problems before resorting
to the use of disciplinary measures. We
considered that there should have been more
communication between healthcare and wing
staff to ensure that her multiple care needs
were adequately met in a holistic way and
concluded that not enough was done to get
a proper understanding of her mental health
and behavioural issues.
Mr L had been in prison for most of
the previous five years when he died.
During this time, his behaviour was
extremely challenging. He flooded
his cell, and covered it in urine and
faeces. Staff often reported seeing
him eat paper plates and other nonedible objects. He occasionally had
periods of lucid behaviour, and some
of the doctors and psychiatrists he
saw thought that he was feigning his
symptoms, although these symptoms
were sustained for some years.
Mr L was found dead one morning in
his cell. A post-mortem examination
concluded that the most likely cause of
death was the result of him blocking his
airway by swallowing some cardboard
from an orange juice carton.

As Mr L had a propensity to eat a range of
materials, eating cardboard was not unusual
behaviour and it did not appear to have been
an act of deliberate self-harm. We found that
staff had made considerable efforts to care
for him, and had taken a multi-disciplinary
approach involving healthcare, wing and
mental health staff. Although there was no
confirmed diagnosis that he had a mental
illness or a personality disorder, he continued
to receive support from mental health teams.
We made no recommendations about his care.

Emerging themes from homicide
investigations
Thankfully, homicides in English and Welsh
prisons are not common but this year we
completed investigations into three homicides
and were notified of two new cases, which
we will investigate once police enquiries and
court proceedings are over. While care must
be taken in extrapolating themes from such
a small number of deaths, our investigations
identified some common issues.
There were examples of Cell Sharing Risk
Assessments (CSRAs) being at odds with
evidence about the person’s risk. On occasion,
prisoners were assessed as medium or
even low risk to others despite a history of
seriously injuring others in custody. It was
not always clear whether these apparently
illogical assessments were a result of staff
not following the process correctly, or key
evidence not being available to the staff
carrying out the assessment, or a combination
of both.

27

WALES

There were also some examples when
information about risk was not effectively
communicated between prisons, meaning
that highly dangerous behaviour in one
prison did not result in appropriate risk
assessment and management in another.
There were also communication breakdowns
within establishments and instances where
warnings about potential risks where not
acted on quickly or effectively. We welcome
the recent publication of the NOMS QuickTime Learning Bulletin to clarify appropriate
use of CSRAs, which reminds staff that the
assessment is an essential tool to enable
identification of prisoners who pose a risk of
serious assault or murder to another prisoner
in any unsupervised shared space. However,
effective risk assessment relies on staff having
all the necessary information and we found
a worrying lack of awareness among some
wing staff about the dangerousness of some
prisoners, even when this had previously
manifested itself in prison. Effective staff
training and robust management checks
will be needed to ensure that the learning
that has been identified brings about real
improvements.
Our investigations into these deaths
highlighted the particular challenges faced
by prisons in managing individuals who are
separated from the main population. Prisoners
are usually given ‘vulnerable prisoner’ status
for their own protection as a result of their
offence, however some prisoners are granted
this status because their behaviour in custody
has put them at risk from other prisoners, for
example by accumulating debts they cannot
pay. In most prisons, vulnerable prisoners live
together on a wing, regardless of the reasons
for their vulnerability. This inevitably presents
challenges over how the risks between
prisoners are managed. Our investigations into
these cases suggest that there remain lessons
to be learned, not least in respect of sharing
information effectively and ensuring that this is
28

appropriately used to inform risk assessments
and management. We have recommended
that in high security prisons, where this is
a particular issue, there should be regular
reviews of vulnerable prisoner status and that
a strategy is developed to manage prisoners in
vulnerable prisoner units who themselves are a
risk to other vulnerable prisoners.
Mr M was killed in a cell by a fellow
prisoner, Mr N, on the vulnerable
prisoner wing of a high security prison.
Mr N had been moved from another
high security prison following the
attempted murder of a prisoner. This
attack also took place on a vulnerable
prisoner wing. Despite Mr N’s history,
on arrival at the receiving prison, his
cell sharing risk assessment made no
reference to the attempted murder
and he was subsequently judged to
present a low risk to fellow prisoners.
Senior managers at the prison were
also unaware of Mr N’s recent violence
and so did not factor this into their
management of him when new
intelligence about his risk to others
came to light. Mr N was able to lock
himself and Mr M into a cell because,
at the time, the practice at the prison
meant that the cell bolt could be
secured from the inside.
Each of the three homicides we investigated
in this period took place in cells, although not
between cellmates. In two of the cases, the
perpetrators were able to lock themselves
in a cell with their victim. In one case, this
prevented staff from entering the cell. In the
other, two members of staff were unaware
of what was happening behind the locked
door. Our investigations raised concerns about
differing practices across the prison estate
in relation to how cell doors are secured to
prevent this.


Family liaison
A fundamental aspect of our investigations
is the involvement of families and friends
of deceased persons. At the outset, our
trained family liaison officers seek their views
on matters we should consider during the
investigation and they are further consulted at
key stages.
During the course of the year, we made 23
recommendations regarding family contact
covering issues such as proper recording of
family contact details, sufficiently early contact
with a terminally ill prisoner’s family and
appropriate contributions to funeral expenses.
As part of the initial reception procedures
on their arrival at prison, staff should ask
prisoners to give contact details for their
next of kin and someone to be contacted
in the event of an emergency. Staff should
then enter this in the person’s record. Not all
prisoners choose to nominate someone to be
contacted, but sometimes it is not apparent
that they have been asked.
Mr O had been in prison for eight
months, when he was found hanging in
his cell at 3.50pm and taken to hospital.
Over two and a half hours after he was
found, the prison appointed a family
liaison officer to liaise with the hospital
and Mr O’s family. No family contact
details had been recorded so they had
to interrogate the prisoner telephone
system to identify a family member that
he had regularly telephoned and then
obtain that person’s address from the
visitor records. This obviously took some
time and his family was not contacted
until 10.50pm that night. Mr O died
four days later.

We have found many examples where details
have not been recorded or are out of date
when needed. This information is essential
in an emergency and it is helpful if prisoners
are reminded that they can provide them or
update them at any time, and are given an
opportunity to do so, particularly if they are
serving a long sentence. Where no details are
given, it is best practice for staff to annotate
the records to indicate the reason why.
In line with the Prison Rules, NOMS guidance
advises prisons to engage immediately
with the prisoner’s next of kin or another
nominated person in the event of a terminal
illness, unpredicted or rapid deterioration in
physical health and as soon as possible after
sudden death. This can include meeting the
prisoner’s family to provide information on the
security arrangements for hospital supervision.

“ During the course
of the year, we made
23 recommendations
regarding family
contact.”

29

WALES

Mr P had a cancerous tumour removed
and, following the spread of the cancer,
he started chemotherapy six months
later. He died 26 months after the
removal of the tumour. Throughout
his time in prison, Mr P had been in
contact with a family member, who
had often visited him. Eighteen months
before his death, an entry in his medical
records suggested that a family liaison
officer should be appointed, but this
was not done until just before Mr P’s
death. In the early hours of the morning
of the day he died, a hospital doctor
requested the details of his next of kin.
The hospital subsequently agreed that
it could wait until the morning. Staff at
the prison could not find any contact
details as they had not been entered in
Mr P’s records. At around 9.30am, the
prison appointed a family liaison officer
and Mr P died an hour later. The family
liaison officer left telephone messages
for Mr P’s next of kin, unaware that he
was abroad. By this time Mr P’s family
had learned of his death through other
prisoners.

We concluded that, if the prison had
established contact with Mr P’s family at
an earlier stage of Mr P’s illness, in line
with Prison Service guidance, the difficulty
about contacting his family would have
been avoided. It is best practice to appoint
a properly trained person, who can act as a
consistent and central point of contact for
families at an early stage when a prisoner is
seriously unwell.
Prison Service instructions require prisons
to offer to pay reasonable funeral expenses
when there is a death in custody. There are
guidelines about what reasonable costs might
include, such as the funeral director’s fees,
a hearse and coffin, but not a headstone,
flowers or clothes for mourners.
Mr Q died from cancer two months
after his diagnosis. The prison had not
appointed a family liaison officer during
his illness but made a commendable
effort to notify Mr Q’s family of his
death in person, even though the prison
was a long way from the family home.
However, the prison paid only a portion
of reasonable funeral costs.
The Governor indicated that he had taken
into account the balance of Mr Q’s private
prison account as well as money for the
family collected by prisoners on his wing even
though the Prison Service instruction expressly
says: ‘A deceased prisoner’s monies must not
be used to meet the cost of their funeral’. We
made a recommendation about the need to
ensure that all reasonable funeral costs are
met, up to the threshold indicated. Although
NOMS accepted the recommendation, the
prison has so far not recompensed Mr Q’s
family. This is an unacceptable response to a
recommendation that has been accepted and
unfair on Mr Q’s family who have not been
treated similarly to others.

30


Although our investigations necessarily tend
to focus on areas for improvement, we
also report on good practice. Prison Service
guidance makes it a mandatory requirement
that prisons have arrangements ‘for an
appropriate member of staff to engage with the
next of kin or nominated person of prisoners
who are either terminally or seriously ill’.
As noted, not all prisons adhere to this
requirement but a number now appoint
trained family liaison officers at a sufficiently
early stage to ensure that families are well
supported, consulted and receive prompt
information about the progression of the
prisoner’s illness. Sometimes, prisons use a
designated member of the healthcare team to
fulfil this function. In either case, we welcome
families having a named person to contact for
information.

Following hospital investigations, a
doctor informed Mr R that he had
cancer and gave a life expectancy
of weeks or months. Owing to the
circumstances of his offences, Mr R
had been estranged from members of
his family. A week after receiving the
prognosis, the prison arranged a special
visit between him, his family and certain
key members of healthcare and prison
staff in a quiet area of the prison. After
the visit, Mr R decided to tell his family
that his illness was terminal and the
lead nurse asked him to compile a list
of family members who it would be
appropriate for her to contact as his
condition worsened. Soon after, the
nurse telephoned the primary family
contact to introduce herself as Mr R’s
key worker and to discuss his condition
and outstanding medical appointments.
She subsequently consulted them about
his wish not to be resuscitated in the
event of a cardiac arrest. She kept in
contact with them with regular updates
as his health declined. When his death
was imminent she gave them the
opportunity to bring forward a planned
visit. She established with them how
they wished to be informed of Mr R’s
death. After his death, a family liaison
officer was appointed, who telephoned
various family members as agreed and
kept in touch as needed.
This was a good example of very effective
family liaison.

31


INVESTIGATING COMPLAINTS


Learning lessons about complaints
Our individual investigations address the
specific issues affecting complainants and
seek to support improvement in the particular
establishments concerned. However, having
completed over 2,000 investigations in 2012–
13, it is also important to identify general
lessons which should be learned across the
system.
A fair and effective disciplinary system is
essential to a safe and controlled prison
environment. Punishments can have a
significant effect on prisoners, so it is no
surprise that complaints about adjudications
are our second most common type of
complaint, behind those about property.
However, it is worrying that last year the
proportion of complaints about adjudications
which were upheld, usually with a
recommendation to quash the finding, rose
from 17% to 38%. This suggests a marked
deterioration in quality. So in March 2013,
it was timely that we should publish a
thematic report on trends in complaints about
adjudications over the last three years, with an
in-depth analysis of our cases in the first six
months of 2012.
The report identified a number of lessons
which reinforce guidance already laid out
in detailed Prison Service Instructions. The
learning is clear: if this guidance was more
closely followed, the quality of adjudications
would be improved and the need for recourse
to the PPO would be reduced.
Two brief learning lessons bulletins were also
published about complaint investigations
last year. The first looked at complaints
from offenders under probation supervision.
Such complaints made up only 7% of all the
complaints we received in the year, but they
raised important issues not least about the

“ It is worrying that last
year the proportion
of complaints
about adjudications
which were upheld,
usually with a
recommendation to
quash the finding, rose
from 17% to 38%.”

process of complaining. The bulletin concluded
that prisons and probation trusts needed to
avoid the ‘buck passing’ of complaints when
they come from serving prisoners yet relate to
issues which occurred in the community.
The second bulletin looked at the challenges
that custody places on an individual’s ability
to practise their religion. In general, prisons
tried hard to accommodate the religious needs
of prisoners but lessons were identified in
relation to how Prison Service Instructions
are interpreted and applied so that an
appropriate balance is struck between security
considerations and religious observance.
The first cross office learning lessons bulletin
focused on sexual abuse in prisons. It looked
at a range of issues including homophobia,
transgender issues, relationships in prison and
allegations of sexual assault during searches.
Lessons were identified regarding strip
searching, conformity with the Equalities Act
2010, addressing abusive intimate relationships
and facilitating police and internal prison
investigations.

33

WALES

Individual complaints
As in previous years, the majority (91%)
of the complaints we received came from
prisoners. This means that changes to the
complaints process in prisons can have a
significant impact on our workload. We
have, therefore, taken a keen interest in
the change to the Prison Service’s internal
complaints procedure this year, switching
from a three-stage process to a two-stage
process. We support this change in principle
as it should enable prisoners’ complaints to
be resolved more quickly in prisons. However,
we have been concerned by the poor quality
of some of the responses by prison staff to
complaints that could and should have been
resolved without the prisoner ever needing to
approach the Ombudsman. This is frustrating
and very unsatisfactory for prisoners and a
waste of our limited resources. The problem
often seems to be that complaints are being
answered by junior staff who do not feel they
have the authority to offer a solution. We are
increasingly sending these complaints back to
the prison to resolve. For example:
Mr A complained that his property
had gone missing when he was
transferred from one prison to another.
Both prisons acknowledged that the
property was missing but took no
further action and simply referred Mr A
to the Ombudsman.

We told the prisons that they needed to
resolve the complaint themselves and offer Mr
A a suitable sum of compensation. We told
Mr A that he should contact us again if the
complaint was not resolved satisfactorily.
We have also continued to decline to
investigate cases that do not raise a substantial
issue or where there is nothing more an
investigation by the Ombudsman could
achieve. For example:
Mr B complained about the noise made
by other detainees playing pool and
watching TV in the communal area
outside his room in an immigration
removal centre. The centre offered to
move Mr B to another, quieter room,
but he refused to move and said that he
wanted the pool table and TV moved
instead.
We told Mr B that we would not investigate
his complaint because we considered that the
centre had already offered him an appropriate
solution.
We are also taking steps to ensure that the
unreasonable behaviour of a few individuals
does not take up a disproportionate share
of our resources to the detriment of other
complainants.

“ However, we have been concerned by the poor
quality of some of the responses by prison staff
to complaints that could and should have been
resolved without the prisoner ever needing to
approach the Ombudsman.”
34


Mr C, for example, has raised a number
of complaints with us – we have
declined to investigate some, have
investigated and not upheld some, and
are still investigating others. Mr C was
unhappy with the decisions we had
made so, in line with our normal policy,
the decisions were reviewed by a senior
manager. Following those reviews the
outcomes remained the same and we,
therefore, told Mr C that we regarded
these cases as closed. However, Mr C
continued to send us frequent lengthy
letters referring to both the closed
complaints and to complaints we are
still investigating. It was difficult and
very time consuming for our staff to
work out which complaints were being
referred to and we, therefore, had to
tell Mr C that we would no longer reply
to letters that refer to closed cases or
to more than one complaint at a time.
We are continuing to investigate his
outstanding cases.
All of these measures are necessary to enable
us to target our resources on the complaints
where this office has a real contribution to
make, and especially on the most serious
complaints.

Serious complaints
Among the most serious complaints we
receive are allegations of assaults by staff, and
we have investigated a number of these this
year, including some worrying cases involving
juveniles and young offenders.
Frequently, these complaints arise in the
context of staff using control and restraint
(C and R) techniques. The issue we need to
address in our investigations, therefore, is

not whether force was used – since there
is no dispute about that – but whether the
use of force was justified (that is, was it
reasonable, necessary and proportionate in
the circumstances). Our task is considerably
more difficult where there is no CCTV or video
evidence (for example, where force is used
spontaneously in a cell). In these cases we
may have nothing to go on apart from the,
often very different, accounts given by the
complainant and staff, at the time and in our
interviews. As a result, it is not always possible
for us to reach a conclusion about what
happened. In a number of cases, however, we
have recommended that disciplinary action be
initiated against the staff involved, such as in
the case below:
Mr D complained that his wrist was
broken in the course of a use of force
incident when he was 16 years old.
The two officers involved said that
Mr D refused an order to go into his
room and stood in the doorway being
verbally abusive and threatening them
with a broom. They said that force was
only used after they tried to persuade
Mr D to release the broom for ‘a good
few minutes’. When one of the officers
tried to push Mr D into the room, the
pair overbalanced and Mr D (who is
slightly built and weighed just over 8
stone) fell to the floor with the officer
(who is about 6 foot 5 inches tall and
weighed about 19 stone) on top of him.
Mr D’s wrists were then put in back
hammers while he was lying face down
before being placed in his room. The
prison told us that Mr D’s wrist had
been weakened by a childhood accident
and had been injured in the gym a
couple of days earlier.

35

WALES

We viewed the CCTV of the incident and
interviewed Mr D and the two officers. It was
clear to us that Mr D’s behaviour was often
difficult to manage and that he had been
verbally aggressive to the officers immediately
prior to the use of force. However, Mr D had
only touched the broom for a fraction of a
second and was no longer doing so when
force was initiated. The CCTV evidence did
not support the officers’ accounts that they
had made a genuine attempt to de-escalate
the situation before force was used. On the
contrary, the CCTV showed one of the officers
standing very close to Mr D, arguing with
him and apparently trying to push him into
the room. In our view, this use of force was
not justified by Mr D’s behaviour and was
particularly unwise given the difference in
their weights. Other staff should have been
summoned to place Mr D in his room in a
controlled manner. Our investigation found
that the officer who initiated force was subject
to poor performance procedures at the time of
the incident as a result of concerns about his
aggressive behaviour and poor communication
skills. We concluded that, although it was
impossible to be sure whether Mr D’s wrist
was actually broken during this incident, there
was no doubt that it was seriously injured as
a result of the use of force – either when he
fell to the floor or when his wrist was placed
in a back hammer – and required immediate
hospital treatment.
We were critical of the fact that the officer
had used a back hammer after he heard Mr
D scream when he hit the floor, and that he
continued to apply it after Mr D screamed
that his wrist was broken. We were also very
concerned that back hammers were used
at all while Mr D was lying face down, since
this could have led to breathing difficulties.

36

We found that the use of force was not
reasonable, necessary or proportionate and
recommended that a disciplinary investigation
be initiated. We were also critical of the
prison’s internal investigation which we
considered insufficiently robust, and we were
un-persuaded by the conclusions of a review
commissioned by the Deputy Director of
Custody.
Another serious complaint we investigated
this year at a young offender institution (YOI)
involved Mr E.
Six officers restrained 19-year-old Mr E
in his cell in the segregation unit one
night. Mr E complained that one of the
officers had punched him in the face.
The officers said that they entered Mr
E’s cell to try to persuade him to stop
setting off the fire alarm and that Mr
E had to be restrained after he jumped
up and lunged at one of them while
they tried to reason with him.
Our investigation found that a number of
young offenders had been setting off fire
alarms and repeatedly ringing their cell bells
in the segregation unit that night (as they
had on previous nights). Although Mr E had
not set off the fire alarm, he had rung his cell
bell four times in the 20 minutes before the
officers went into his cell. Mr E accepted that
he had jumped up while the officers were in
the cell and, in the absence of CCTV evidence,
we were unable to say that the restraint in
the cell was not justified or that Mr E had
been punched in the face. However, it is very
unusual for staff to enter a cell during the
night patrol state – this would only normally
happen if a prisoner were ill or injured. We
considered that it had been unnecessary and
unwise for the officers to go into Mr E’s cell


and that the officers’ behaviour amounted
to deliberate provocation contrary to the
Prison Rules. We were also concerned that
the statements the officers completed after
the restraint lacked the necessary detail, that
Mr E was not debriefed afterwards (as he
should have been) and that the YOI’s own
investigation into Mr E’s complaint had been
wholly inadequate. We recommended, among
other things, that the Governor of the YOI
commission a disciplinary investigation into the
actions of four of the officers and apologise
to Mr E for the unsatisfactory way in which his
complaint was investigated.
Not all serious complaints are about the use of
force. For example:
Ms F complained that a male officer
had submitted negative reports about
her behaviour after she rejected his
sexual advances. Our investigation did
not find any evidence to support the
specific details of Ms F’s complaint and
we did not uphold it. However, in the
course of our investigation, another
prisoner, Ms G, told us that she had
had a sexual relationship with the same
officer in return for him bringing items
into the prison for her, and that she had
submitted an internal complaint about
him after transferring to another prison.
It also emerged that other prisoners
had made similar allegations about this
officer over a number of years.

This did not necessarily mean that the
allegations about this officer were true, but
we were concerned that the prison’s internal
investigation into Ms F’s complaint had not
taken the previous allegations into account.
We recommended that the prison should
commission a disciplinary investigation into
Ms F’s allegations and that this should take
account of the previous allegations about the
officer.
The failure to conduct a robust internal
investigation is one theme that emerges from
a number of these serious complaints. Another
concern is that relevant CCTV footage of
the events before and after a restraint is not
always retained even after a complaint has
been made. This was an issue, for example, in
this case:
Mr H complained that he was physically
and sexually assaulted by staff during
the course of a restraint. The restraint
took place in a cell and there was,
therefore, no CCTV coverage. Our
investigation did not provide evidence
to support Mr H’s complaints and we
did not uphold it. However, we were
concerned that the CCTV footage that
showed Mr H being taken into the cell
had been destroyed as a matter of
routine after nine days, despite the fact
that Mr H had submitted complaints to
the prison. Although the CCTV footage
did not cover the restraint, it would
have provided useful evidence of Mr H’s
behaviour which staff said had made
the restraint necessary.

“ The failure to conduct a robust internal
investigation is one theme that emerges from a
number of these serious complaints.”
37

WALES

As the destruction of CCTV footage had
arisen in other cases, we made a national
recommendation to the Prison Service that
any CCTV of a use of force, and of the
period before and after, should be retained
as evidence for a period of three months if a
prisoner makes a complaint about the use of
force.

We recommended that the Governor carry
out an investigation into the appropriateness
of these decisions. We also made a national
recommendation during the year that the
Prison Service should amend PSO 1700 at
the next available opportunity to make it
mandatory to record strip searches and the
reasons for them.

Mr H also complained about being stripsearched unnecessarily after the restraint
and this was another theme to emerge from
complaints about the use of force during the
year. A strip search is one of the most intrusive
actions that can be taken against a prisoner
and for this reason Prison Service policy,8
rightly requires that such searches should only
take place where there are high risks, serious
concerns and good reasons to suspect that a
prisoner has secreted items.

We have also dealt with complaints from
prisoners who feel they have not been
protected from assaults by other prisoners.

Our concerns are illustrated in the following case:
Mr I was strip-searched by force
following a restraint in a high security
prison. Our investigation found no
evidence that a risk assessment was
conducted to consider whether it was
necessary to do a strip search and we
concluded that it was most likely that
it was done as a matter of routine.
We also found no evidence that a risk
assessment was conducted to consider
whether it was necessary to strip search
Mr I by force, or that any attempt was
made to secure his compliance first, and
we concluded that it was most likely
that this was also done as a matter
of routine. Staff did not appear to
recognise that a decision to strip search
and a decision to strip search by force
were two separate decisions and that
both needed to be justified and the
reasons recorded.
Prison Service Order 1700 (which refers to strip
searches as “full searches”)

8

38

Mr J complained that he had been
subjected to homophobic abuse,
threats and an actual assault by another
prisoner and that prison staff had failed
to protect him. Our investigation found
that the relationship between the two
prisoners was more complicated than
Mr J had suggested, and that there was
some evidence that the other prisoner
had been responding to taunts by Mr J.
We also found that the other prisoner
had been challenged by staff about
homophobic comments on at least
one occasion, and had been placed
on report following the assault. In
addition, the prison had taken steps to
separate Mr J and the other prisoner.

“ Any CCTV of a use of
force, and of the period
before and after, should
be retained as evidence
for a period of three
months if a prisoner
makes a complaint about
the use of force.”


However, we were concerned that most of the
incidents between the two prisoners had not
been recorded and that it had taken the prison
four months to provide Mr J with a response
to his concerns. We recommended that the
prison improve the way they record and
respond to complaints of this kind.

Links with the outside world
Keeping prisoners and detainees safe is a
fundamental requirement, but other issues
may also be very important to those who have
lost their liberty. One is the ability to maintain
relationships with the people they care about
in the community. Some of the complaints we
receive about this subject are straightforward
ones (for example, about delays in approving
the telephone numbers of relatives), but others
are more complex and involve a balance of
competing needs.
Mr K complained about the prison’s
decision to stop his 11-year-old
daughter visiting him. Our investigation
found that Mr K was serving a sentence
for a sexual offence against a 16-yearold girl and that the visits had been
stopped after staff had expressed
concern about what they considered
inappropriate behaviour by Mr K when
his daughter sat on his lap during a visit.
Mr K strongly refuted the suggestion
that there had been any inappropriate
behaviour.
We were in no doubt that the prison had
been absolutely correct to take the concerns
expressed by staff very seriously and to
investigate them. There is no question that
the need to protect Mr K’s daughter should
take precedence over Mr K’s right to a family
life. However, stopping contact between
a parent and a child will have a significant
impact on the child as well as the parent, and

is not a decision that should be taken lightly.
We were, therefore, surprised to find that the
investigation in this case had apparently been
carried out as a paper exercise only, without
interviews with the staff or Mr K, and that
there was no record of what evidence had
been considered or what decisions had been
taken. We recommended that a fresh risk
assessment should be carried out within three
months.
Mr L complained that he had been
refused permission to attend his
father’s funeral under escort. Mr L said
that he had been told that the police
and probation services objected to his
attendance, but he knew this was not
the case. The death of a parent is a very
distressing event and it was natural that
Mr L should have wanted to attend
the funeral. However, he had been
convicted of a serious sexual offence
against the daughter of his former
partner and it was, therefore, necessary
for a thorough risk assessment to be
carried out to determine whether his
request could be approved.
Our investigation found that the risk
assessment showed that the police and
probation services did not oppose Mr L’s
attendance; that he was not considered to
be an escape risk; that his victim and her
mother now lived over a hundred miles away
and would not be present at the funeral; and
that Mr L’s family had undertaken to ensure
that no other children would be present.
We concluded that, motivated by the need
for a quick decision, the decision maker had
failed to read the risk assessment reports
properly, and that the refusal was, therefore,
based on incorrect reasoning. We upheld
Mr L’s complaint and recommended that the
Governor apologise to him. We were pleased
to note that, although Mr L had not been
39


able to attend the funeral, the prison had
nevertheless acted with sensitivity and had
offered him support at the time of the funeral
and the opportunity to visit his father’s grave
at a later date.
We receive frequent complaints from prisoners
that their legally privileged mail has been
opened by staff in contravention of Prison Rule
39. Prisons may not open or read mail from a
prisoner’s legal adviser or certain other bodies
(such as courts), unless they have reasonable
cause to believe that it contains an illicit
enclosure or is not from a body covered by
Rule 39. Where such mail is opened, it must
only be done in the presence of the prisoner
and must be recorded in the correspondence
log.
Mr M complained that his letters from
courts and solicitors were being opened
routinely. We found that there was
evidence that some of Mr M’s letters
had been opened by mailroom staff
despite being clearly marked ‘Rule 39’.
There was nothing on the envelopes
to identify the senders, and it was,
therefore, reasonable for staff to
have questioned whether they were
genuinely from a body covered by Rule
39. However, if there were doubts, the
letters should have been opened in Mr
M’s presence and not in the mailroom.
We also found that, although it would
have been obvious to staff once the
letters had been opened that the
contents were legally privileged, the
error had not always been recorded
in the correspondence log. We did
not find any evidence that Mr M’s
Rule 39 mail was being deliberately
or systematically opened, and we
concluded the problem had arisen
as a result of poor management and
training.

40

We recommended that the Governor
apologise to Mr M for the errors in opening
his mail. We also recommended that the
Governor conduct a formal review of the
prison’s mail handling arrangements and
arrange retraining for all the staff involved.

Property
Complaints about lost and missing property
have continued to make up the largest single
part of our complaints work (18% of all
complaints investigated in 2012–13). The sums
of money are usually small, but most prisoners
have few possessions and those they do have
may be an important source of personal
identity.
We uphold a higher percentage of property
complaints than many other types of
complaints (53%), and we continue to be
concerned about the cavalier and unhelpful
manner in which these complaints are too
often treated by prison staff (as the case of Mr
A above illustrates).


“ We uphold a higher
percentage of property
complaints than
many other types of
complaints (53%).”
Mr N complained that his property
was stolen from his cell while he was
in hospital after being assaulted by
other prisoners. The prison told Mr N
that staff had locked his cell when he
was taken to hospital, but that other
prisoners had broken in and stolen his
belongings. They told Mr N that his
property was held at his own risk and
that the prison was not responsible for
its loss. They did, however, offer him
£50 in full and final settlement. Mr N
complained to the Ombudsman that
this was significantly less than the value
of the stolen items.
We were disappointed that the prison had
told Mr N that he was responsible for his own
property since, when he was taken to hospital,
he was no longer able to take care of it and
responsibility passed to the prison who should
have taken steps to secure the property and
to record it. We were also surprised that the
prison had not conducted an investigation into
how other prisoners had been able to break
into a locked cell. Our investigation suggested
that the prison had underestimated the value
of Mr N’s property and we mediated a more
appropriate settlement.
Of course, not all the complaints we receive
about property are upheld.

Mr O complained that £200 in cash sent
to him by his partner, had not been
credited to his prison account. Our
investigation established that that Mr
O had received £20 in cash in a card
from his partner, and that the prison
had endorsed the envelope to record
that it had contained £20 and had
credited the money to Mr O’s account.
We examined the letters and envelopes
that Mr O provided to support his
complaint. We concluded that Mr O had
made amendments to a letter to make
it appear that it had contained £200,
and that he had altered the prison’s
endorsement on the original envelope
from £20 to £200.
We did not uphold Mr O’s complaint.

Adjudications
Adjudications give rise to a significant number
of complaints each year. The Ombudsman’s
role in considering these complaints is not to
rehear the evidence, but to decide whether,
based on the evidence heard at the hearing,
it was established beyond reasonable doubt
that the prisoner did what he was charged
with doing, that the correct procedures were
followed, and that a fair and just decision has
been reached. We have seen some poorly
conducted adjudications this year, and in
about 38% of the adjudication complaints we
investigated we concluded that the finding
of guilt was unsafe – usually because the
adjudicator failed to call witnesses without
good reason, or failed to enquire fully into
the prisoner’s defence, or failed to provide
reasons for the decisions made. Poorly
conducted adjudications are a concern, not
least because they can result in prisoners being
punished unfairly or in guilty prisoners going
unpunished.

41

WALES

Eighteen-year-old Mr P complained
about being found guilty of assaulting
an officer. The details of the charge
were that, during an association period,
an officer had been seen emerging
from Mr P’s cell in a confused state with
a cut to his lip. When asked what had
happened, the officer said that Mr P
had pushed him. Mr P denied that he
had assaulted the officer.
Our investigation established that neither the
alleged victim, nor the officer who had found
him, were present at the adjudication hearing
and that statements from them were read
out instead. Mr P did not, therefore, have an
opportunity to question the evidence against
him. This is contrary both to Prison Service
policy and to natural justice. The adjudicator
did not seek any further evidence to establish
that the alleged victim had suffered any
injuries consistent with his account or that Mr
P had been in the cell at the time. He relied
solely on the disputed hearsay evidence to find
Mr P guilty.
We considered that the finding was unsafe
and recommended that it be quashed.
We did so with great reluctance. Mr P had
been charged with a serious and wholly
unwarranted attack on an officer carrying
out his duties. If that is what happened, the
alleged victim had a right to expect that the
perpetrator would be punished. We would
normally have expected that a charge of
this seriousness would be referred to an
independent adjudicator (a judge) and no
explanation was provided for why that had
not happened in this case. Assuming that
there was a good reason, the onus was on
the adjudicating Governor to take pains to
ensure that the adjudication was procedurally
correct. Unfortunately, he failed to do so.
We recommended that he receive refresher
training in the conduct of adjudications.
42

The following case raised a different issue:
Mr Q complained that he had not been
given long enough to obtain legal
advice when he was charged with
using homophobic language towards
an officer when asked to comply with
a strip search. Our investigation found
that the hearing was adjourned for a
little over 48 hours to allow Mr Q to
obtain legal advice. When the hearing
resumed, Mr Q asked for further time.
The adjudicator refused, saying that
Mr Q had already had sufficient time
to obtain legal advice. He proceeded
to find Mr Q guilty and imposed a
punishment of cellular confinement and
loss of canteen, association, television
and gym.
Prison Service Instruction (PSI) 47/2011 on
discipline procedures says that prisoners who
request legal advice must be given ‘sufficient
time’ to consult a legal adviser, and that it
is for the adjudicator to decide how long
to allow ‘but two weeks will normally be
enough’. We did not consider that 48 hours
was sufficient time for Mr Q to obtain legal
advice and we, therefore, recommended that
the guilty finding be quashed as unsafe. The
Governor disagreed, saying that prisoners
were not routinely locked up during working
hours and that Mr Q would, therefore, have
been able to telephone his solicitor. Most
unusually, the Chief Executive of NOMS did
not accept our recommendation to quash the
finding.
We do not consider that prisoners should be
able to string adjudications out unreasonably,
and we do not consider that prisoners should
always be given two weeks to obtain legal
advice. However, it remains our view that 48
hours will not normally be sufficient time for a
person who is detained and has limited access
to the telephone, and none to fax or email,


to obtain advice from a solicitor who has not
seen the papers and who will need to sort out
funding issues. It is simply unrealistic to expect
that prisoners will be able to obtain instant
legal advice over the phone in the majority of
cases.

Religious issues
We have continued to receive complaints
about religious issues. One of the most
significant was that of Mr R.
Mr R complained that the Prison Service
did not recognise Rastafarianism as a
religion. The Prison Service told us that
they were bound by a 30- or 40-year-old
Ministerial decision that Rastafarianism
should not be recognised as a religion,
but that they did nevertheless support
the religious and cultural needs of
Rastafarian prisoners. They also
recognised that the current policy
was out of date, as the Equality Act
2010, which recognises Rastafarianism
as a religion, overrides any previous
Ministerial decision.
We found that the Prison Service’s policy
on Rastafarianism contravened the Equality
Act, and we recommended that the Prison
Service should issue guidance to all Governors
reminding them of the need to comply with
the Equality Act.
Mr S complained that celebrations for
the Muslim festival of Eid had been
cancelled at his prison.
Our investigation found that the Eid
celebrations had not been cancelled. Prayers
would take place in the prison’s chapel and
sweets and snacks would be distributed there.
However, because the prison chapel was not
equipped for dining, it had been decided that

celebratory meals for all religious and cultural
meals (including Eid) would in future be served
on the wing and not in the chapel. The meals
would be made available to all prisoners in
order to encourage an understanding of other
faiths. As there were very few Muslims on
Mr S’s wing, they would be allowed to join
Muslim prisoners on another wing for the
meal. The local imam had confirmed that this
arrangement met the religious requirements.
We were satisfied that the arrangements had
been made after appropriate consultation
and with the support of the imam, and we
considered that they were entirely reasonable.
We did not, therefore, uphold Mr S’s
complaint.

Categorisation
Being able to progress through their sentence
towards release is, understandably, important
to prisoners and we, therefore, receive a
number of complaints from those who
believe they have unfairly been refused recategorisation to a lower security category.
Mr T complained that he had been
refused re-categorisation to category
D (which would have allowed him to
transfer to an open prison) on the
grounds that he was suspected of
involvement in the supply of drugs
and mobile phones in the prison. Mr T
denied this and said that, although he
had once been caught with a mobile
phone in his possession, he had never
had a positive drugs test and had never
been found in possession of drugs.
Our investigation found that Mr T’s custodial
behaviour had been good throughout the
previous two years. However, he had twice
been caught with a mobile phone, and there
had been 25 security intelligence reports
(mostly from reliable sources) linking him
43

Ppo annual-report-2012-13

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